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illinois-county-mapAt Amvik Solutions we understand that providing meaningful, quality, specialized ABA treatment is the number one priority for your agency and your providers. However, prior to scheduling or performing any ABA services, it is essential that you complete the prior authorization process to ensure that you are legally qualified to provide services for a particular insurance.

If you are not already credentialed with a specific insurance company, you may not be able to receive payment for any out-of-network claims. Being credentialed allows you to become an in-network provider, while also providing you additional exposure to patients and families that may be in need of ABA therapy.

If you aren’t sure where to begin, then consider the following frequently asked questions for obtaining preauthorization for ABA treatment from BCBS in the state of Illinois:

  1. Is it true that preauthorization is now required for patients to receive Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder?

Effective Jan. 1, 2017, benefit preauthorization will be required for BCBSIL PPO members to receive Applied Behavioral Analysis (ABA) services for the treatment of Autism Spectrum Disorder. Providers may request benefit preauthorization on behalf of members by calling the number on the member’s ID card. The call must be made at least one business day prior to the scheduling of the planned outpatient service.

  1. What is the process to becoming preauthorized?
  • Eligibility and benefits must be obtained by the member in order to secure prior authorization.
  • Eligible members must have a diagnosis of Autism Spectrum Disorder from a qualified diagnostician.
  • An initial functional assessment, including a treatment plan that identifies any deficient skills and the appropriate interventions, must be completed by the servicing provider.
  • After the first benefit preauthorization for ABA services, additional benefit preauthorization requests may require concurrent review to ensure the member continues to meet the medical necessity guidelines under their benefit plan.
  • Submission of three forms will be required:
  1. Diagnostic Physician/Specialist Evaluation
  2. Provider Credentials
  3. Verification, Assessment Information and Initial Treatment Plan
  1. Where can I get the forms for preauthorization?  

Please find the required preauthorization forms linked below:

  1. Applied Behavioral Analysis Benefit Preauthorization Requirement for PPO Members
  2. Initial Treatment Request – Form #1
  3. Initial Treatment Request – Form #2
  4. Initial Treatment Request – Form #3
  5. Managed Care/Concurrent Review Form
  1. Is F84.0 the only acceptable diagnosis eligible for ABA therapy?

Yes, children under the age of 21 who have health coverage through an individual or group policy, as described above, will receive coverage for the diagnosis and treatment of autism spectrum disorder.

  1. Does the location of where the ABA treatment will be provided affect benefits?  

It depends on each member’s individual policy. Typically, benefits are different if services are provided either at home or at an office. Please make sure to ask specific questions about benefits based on potential place of service.

  1. How long does an authorization typically last for?

Usually, an authorization is for 6 months at a time. It can vary based on the treatment plan.

  1. Is retro-authorization a possibility? If yes, how far are you able to go back?

Yes, a retro-authorization is possible. This is dependent on a member’s policy, so they must call their insurer in order to find out the specifics regarding this situation.

  1. Do preauthorization requirements apply to both fully-insured and self-funded groups?

Yes, but self-funded groups have the option of dropping these requirements at any given time, with or without notice.

  1. Are there any differences in the clinical review guidelines for self-funded vs fully-insured policies?

No, but self-funded groups have the option of waiving the preauthorization requirement.

  1. What number should I call if I have questions about preauthorization?  

Contact BlueCross Blueshield of Illinois at 800-851-7498 if you have specific questions regarding preauthorization.

  1. What if we are given incorrect information about benefits and told preauthorization is not required only to find out that preauthorization was required?  

Please note that verification of eligibility and benefits, as well as the fact that service or treatment have been preauthorized or predetermined for benefits, is not a guarantee of payment. Benefits will be determined once a claim is received, and will be based upon various criteria including the member’s eligibility, as well as the terms of the member’s certificate of coverage applicable on the date services were rendered.

  1. How can Amvik Solutions Inc. help in obtaining authorizations?

This is just one of the many services provided by Amvik Solutions. We will work together with you to get all the required documentation together and contact the insurance company on your behalf to obtain the preauthorization.

Please do not hesitate to contact us for a free consultation regarding preauthorization or any of the other services we provide. Call us today at (805) 277-3392 to find out how we can help you get credentialed and doing what you do best – providing superior ABA services.